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Employer Name:
Employee Name:
Federal W-4
Status
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Single
Married
Married (withhold as single)
Exempt
Allowances (Line 5)
Additional W/H (Line 6)
State W-4 (or equivalent) - of applicable
Status
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Single
Married
Married (withhold as single)
Exempt
Allowances
AZ Only (Percentage)
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0%
.8%
1.3%
1.8%
2.7%
3.6%
4.2%
5.1%
Confirmation
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The church has a signed Federal/State (if applicable) copy of the W-4.
Submitted By (Initials):
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Phone Number
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Area Code
Phone Number
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